Health History Update Template
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Dear Parent/Guardian,
In preparation for the upcoming IEP meeting to review your child’s special education program, updated health
information will assist us to better serve your child’s needs in school.
Please answer ALL of the following
questions regarding your child’s health in the past year. When complete, return this form to the Health Office.
Thank you.
Student: __________________________________ Birthdate: _____________
Today’s Date: ____________
Person completing form: __________________________________ Relationship: _______________________
Preferred phone number: (
) __________________ Email: _______________________________________
Current Primary Physician:__________________________________________ Phone: (
)__________________
Other Physician(s):________________________________________________ Phone: (
)__________________
Current counselor/therapist (if applicable) _____________________________ Phone: (
) _________________
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Name of health insurance: __________________________
None
I would like assistance obtaining insurance
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My child wears glasses or contact lenses for:
Distance
Reading
Constant Last eye exam
__________
(date)
In the past year, has your child had ear infection, tubes, or other hearing problems? ___________________________
Does your child have any dental problems? ________________________ Date of last dental exam ______________
How many meals does your child eat daily? _______________ How many servings of milk daily? ________________
Does your child need a special diet?
__________________________________________________
If yes, please specify
Does your child eat a variety of foods (fruits, vegetables, meat, etc.)? ______________________________________
Do you have any concerns about your child’s nutrition? __________________________________________________
Normal school night bedtime _________ PM
Normal weekend bedtime ___________
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Normally awakens at ____________ AM
on own
with alarm clock
by parent/guardian
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My child has
no sleep problems
difficulty falling/staying asleep
difficulty waking up
frequent nightmares
Does your child participate in organized sports? ________________________________________________________
Is your child active outside of school? ________________ Any activity restrictions? __________________________
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In the past year, was your child observed or hospitalized because of a head injury or concussion?
Yes
No
If yes, please explain _____________________________________________________________________________
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Do you have concerns about your child’s activity level?
Yes ____________________________________
No
Please list your child’s extracurricular activities
_______________________________
(scouts, music lessons, clubs, etc.)
Average # of hours per day spent on computer __________ video games __________ watching TV __________
Do you have concerns about alcohol, bullying, drugs, sexual activity, or smoking for your child? ___________________
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My child consistently wears:
seatbelt
sunscreen
helmet
protective gear
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In the past year, has your child had any serious illness, injury, surgery, or hospitalization?
Yes
No
If yes, please explain, including approximate date, treatment, outcome. _____________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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